Provider Demographics
NPI:1023498359
Name:COOK, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5100
Mailing Address - Country:US
Mailing Address - Phone:870-530-4234
Mailing Address - Fax:870-336-0061
Practice Address - Street 1:1699 RED WOLF BLVD
Practice Address - Street 2:SUITE I
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5442
Practice Address - Country:US
Practice Address - Phone:870-336-0543
Practice Address - Fax:870-336-0061
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR40381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice